OBTURATOR INFECTED HEMATOMA AND URETHRAL EROSION FOLLOWING TRANSOBTURATOR TAPE IMPLANTATION

Abstract

Since the introduction of the tension-free vaginal tape (TVT) procedure as surgical treatment of female stress urinary incontinence, several tape and other minimally invasive procedures have been developed. The transobturator tape (TOT) procedure was developed to reproduce, through the obturator and puborectalis muscles, the natural suspension fascia of the urethra.1 This procedure was developed to prevent bladder perforation and is considered to be associated with a low morbidity.1 We report a case of infected hematoma and urethral erosion following the transobturator tape procedure. To our knowledge this is the first case of urethral erosion and the second case of infected hematoma reported in the literature. CASE REPORT A 43-year-old woman with a history of hypothyroidism, depression, appendectomy and uterine fibroma was referred for lateral right labia majora pain radiating to the internal face of the thigh, increased at the sitting position, associated with a purulent vaginal flow and dyspareunia. The patient had been treated 6 months earlier for isolated stress urinary incontinence by a suburethral nonwoven, nonelastic polypropylene tape placed through the obturating membrane. Symptoms appeared on postoperative day 1. Physical examination showed an anterior vaginal erosion associated with a purulent flow. Bacteriological study of the vaginal flow revealed group B streptococcus. With the patient under general anesthesia vaginal examination demonstrated a urethral erosion opposite the silicone portion of the tape. Faced with the impossibility of removing the totality of the tape, only the silicone portion was removed. The urethra was sutured, and the paraurethral spaces were abundantly washed with a mixture of povidone iodine and serum. The edges of the vaginal erosion were resected and a suprapubic catheter was placed. At 48 hours postoperatively pain persisted, and opposite the obturating hole an inflammatory, hot, painful tumefaction appeared. This abscess was evacuated and drained surgically. At the bottom of the abscess the right portion of the tape was found and easily extracted. The pain then disappeared but the vaginal flow persisted associated with recurrence of the urethrovaginal fistula. The left portion of the tape was then removed by a transobturator route and the vaginal flow disappeared. One month later urethroplasty was performed. Three months later the vagina and the urethra were cicatrized, and the patient remained continent.